Clinical Scales for Paroxysmal Sympathetic Hyperactivity in Pediatric Patients

Abstract

Dear Editor:

We have read with interest the article from Baguley and colleagues,¹ in which they describe the procedures and results of a Consensus Committee on the nomenclature and diagnosis of paroxysmal sympathetic hyperactivity (PSH) episodes. Such a consensus was needed because, as the authors also point out, there has been a progressive rise in the number of articles published each year regarding PSH. Besides the increased awareness of neurologists, it can also be speculated that progress in the field of intensive care will contribute to the survival of a larger proportion of brain-traumatized patients, who may manifest PSH throughout rehabilitation.

The diagnostic tools proposed are indeed highly valuable to standardize findings from different structures and medical staffs. These tools, developed for an adult population, also could be adapted for pediatric use. As published data on pediatric PSH may not be sufficient to allow the production of a consensus document, useful information may come from the clinical practice of a number of centers that regularly treat patients with PSH.

In our pediatric rehabilitation center (Scientific Institute IRCCS E. Medea, Bosisio Parini [LC] Italy), we recently set up a very similar scoring system, designed from a set of retrospective observations and in accordance with European reference values for pediatric life signs.² This tool, shown in Table 1, is in current use in our clinical routine to assess the severity of acute PSH episodes. Each episode scored by this system is added to a daily PSH score.

Table 1.

Pediatric Paroxysmal Sympathetic Hyperactivity Scoring Reference

	0	1	2	3
Heart rate	1–4 years: <110	1–4 years: 110–124	1–4 years: 125–139	1–4 years: ≥140
	5–15 years: <100	5–15 years: 100–119	5–15 years: 120–139	5–15 years: ≥140
Respiratory rate	1–4 years: <30	1–4 years: 30–34	1–4 years: 35–39	1–4 years: ≥40
	5–15 years: <25	5–15 years: 25–29	5–15 years: 30–34	5–15 years: ≥35
Systolic blood pressure	1–4 years: <100	1–4 years: 100–109	1–4 years: 110–119	1–4 years: ≥120
	5–15 years: <120	5–15 years: 120–129	5–15 years: 130–139	5–15 years: ≥140
Diastolic blood pressure	1–4 years: <65	1–4 years: 65–72	1–4 years: 73–79	1–4 years: ≥80
	5–15 years: <75	5–15 years: 75–82	5–15 years: 83–89	5–15 years: ≥90
Temperature	<37°C	37–37.9°C	38–38.9°C	≥39°C
Sweating	Normal	Increased sweating	Localized diaphoresis	Generalized diaphoresis
Muscle tone increase	Absent	Mild increase	Neat increase	Generalized spasticity or opisthotonus

While our pediatric scoring system agrees on most of the items that compose the Diagnosis Likelihood Tool proposed by Baguley and colleagues,¹ it differs in specific aspects. One of these is the evaluation of diastolic blood pressure. In our experience, pediatric patients with PSH may present with either an elevation of the diastolic or systolic blood pressure only; therefore, both parameters could be evaluated separately, yielding more information. In our practice, we also consider single daily PSH episodes, as long as they repeat consecutively at least once per day over 1 week.

The evolving agreement in the international neurological community is proof that a common course is emerging toward an essential and correct interpretation of PSH. This systematization will hopefully lead to a rationalization of drug therapies that, in the field of PSH, are currently carried out based on isolated observations.^3
–5 Ideally, a large multicentric study should be performed.

Footnotes

Acknowledgment

The financial support by Agenzia Italiana del Farmaco (AIFA) and Regione Lombardia (MEAP Project, Monitoraggio degli Eventi Avversi in Pediatria, to EC) and by the Italian Ministry of Health (Ricerca Corrente 2014, to EC and SS) is gratefully acknowledged.

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